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Please help with DX coding

  1. #1
    Default Please help with DX coding
    Medical Coding Books
    Have a patient that had a partial excision of the clavicle and MD states that patient is having dysfunction because of the absent clavicle.

    How would you code this??

    This is the exact wording from the MD for the Dxes.

    "Right shoulder impingement with scapular dyskinesia and some dysfunction because of the absent clavicle"

    So I have

    726.2 and 781.3

    I was thinking of maybe using 736.89 other acquired deformities of other parts of limbs.

    Suggestions would be greatly appreciated. Thanks
    Tina Wosmek CPC, COSC

  2. #2
    Location
    Columbia, MO
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    12,531
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    I am not having a problem with your choice of codes but I would also add a late effect code to show this is a late effect of either an injury or surgery. (905-909)

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    only problem is that the MD did not know why the patient had the clavicle excision and the patient was a poor historian i guess, was done by another clinic and no notes. So if I did would I use an unspecified late effect 908.9?? or 909.9 completely unspecified as we have no idea if it was an injury or a disease that resulted in the excision.
    Tina Wosmek CPC, COSC

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    In that case go with the 909.9. It may be important down the road that this be identified as a late effect.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Default
    Thanks
    Tina Wosmek CPC, COSC

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